This work is typical of the efforts of the gifted practitioner concerned with an important problem encountered in pediatric practice. It has all the limitations which time and sampling impose and does not satisfy the more precise investigative criteria for control populations, statistical treatment and other considerations which further studies by this group may encompass. It represents an effort which seeks a practical solution and it enlists allies in a well known safety organization. It is the method of collaboration and the clues that are developed which makes this paper a vital contribution. The practitioner requires supportive workers in this type of investigation, but is in a superb position to give additional information about the child and his family, and to implement findings that might be related to prevention. The "event tree" method of study and action which is proposed and illustrated offers a model for injury control of many types. Community workers who are concerned about the problem of falls as the leading method of childhood injury are hereby offered a useful method of study which does not require extensive or complicated efforts. The leads that the paper offers with respect to cultural differences in types of falls and circumstances should be explored. It is unclear either in this work or in the literature whether the method of control posters, campaigns, etc. are indeed effective or not. All existing methods of fall control should be encouraged as they raise the level of awareness of the hazards to children, but a number of investigators have indicated that it is the mother's attitude and distractions from childbearing which offer a strong current of causation. Approaches with the same population using evaluated techniques suggested by the authors are a next step.
Correspondence to Harvey Kravitz, M.D. 9243 Avers, Evanston, Ill. 60203. ! NJURY TO THE EARS and impaction of cerumen in the external auditory canals, with hearing loss caused by cotton-tipped swabs, has not received the attention it deserves in the literature. This report describes studies carried out to determine the frequency of such problems in children and adults. MethodsThe authors, who included three pediatricians and two otolaryngologists, collected data on ear diseases and disturbances related to cotton-tipped swabs seen in their practices for one calendar year. These data included: 1) cases of traumatic injuries to the external auditory canal, the tympanic membrane, and the structures within the middle ear; 2) causes of impaction of cerumen in the external auditory canal; 3) cases of otitis ' externa. The cases of traumatic injury to the ear and its internal structures were reported by the parent or adult to have occurred immediately after the insertion of cottontipped swabs in the external auditory canal.The cases of otitis externa and impaction of cerumen were attributed to cotton-tipped swabs if a mother had been inserting them into the external auditory canal one or more times a week to clean the cerumen out of the ears of the child, or an adult had been doing it to himself.Also determined was the incidence of impaction of cerumen caused by daily to weekly use of cotton-tipped swabs in the external auditory canals. We studied the children of 100 randomly selected mothers in a suburban private pediatric practice, and of 100 other mothers from an inner-city population from the outpatient clinics of Children's Memorial Hospital, Chicago, Illinois.
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